Two hours into a fresh frozen plasma transfusion, a 45-year-old woman develops acute severe hypoxaemia, fever, and hypotension. Chest radiograph shows bilateral perihilar infiltrates without cardiomegaly, and the CVP is low. The plasma came from a multiparous female donor. What is the most likely mechanism?
- A Donor anti-HLA and anti-neutrophil antibodies attacking recipient pulmonary endothelium ✓
- B Volume overload from the transfused plasma
- C Recipient antibodies against donor red cell antigens causing intravascular haemolysis
- D Bacterial contamination of the plasma unit producing endotoxaemia
Explanation
The picture is transfusion-related acute lung injury (TRALI): acute hypoxaemia with bilateral infiltrates within six hours of transfusion and no evidence of volume overload. Multiparous female donors commonly have anti-HLA and anti-neutrophil antibodies from pregnancy, which bind recipient leucocytes and pulmonary endothelium, causing capillary leak. The absence of cardiomegaly and normal filling pressures excludes TACO, and the lack of haemoglobinuria or haemoglobinaemia excludes haemolytic reaction. Management is stopping the transfusion and supportive oxygen or ventilation.
Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.